the big picture of making the business case for infection prevention and control

7/30/2019 The Big Picture of Making the Business Case for Infection Prevention and Control

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The Big Picture of Making a BusinessCase for Infection Prevention and

ControlConnie Steed, MSN, RN, CICDirector, Infection Prevention

Greenville Health System

Greenville, S.C.


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Objectives Identify the burden, including the cost of healthcare-

associated infections (HAIs).

List key components to establishing a business plan/case.

Discuss how infection preventionists can demonstrate value

to the organization.


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Current Landscape Enhanced scrutiny of HAI

Public/consumer groups

Legislators; National HAI Plan Payors and regulatory agencies

Legal liability

Patient safety initiatives

Expectation of best practices Prospects of decreased payment

Increased pressure on administrators to reduce infectionrates>>>Focus on infection prevention


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Messages on HAIs From the FederalAction Plan

1. Many HAIs are preventable.

2. A systemic approach to reduce disease transmission can bemore effective than disease-specific approaches.

3. Developing and supporting research to address gaps in thescience in HAI prevention will generate additional

preventive strategies.4. Strong partnership between federal and local/state

governments and communities is vital. HHS is committed.


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Messages on HAIs From the FederalAction Plan continued

5. Preventive steps to control and prevent HAIs are cost-

effective, save lives, and reduce disability for Americans.

6. The time to act on HAIs is now, and HHS and its partners areworking closely with providers, health systems, community

leaders and government to help prevent HAIs.


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Type HAI Attributable Costs

Mean (SD)

Range

Surgical Site $25,546 (39,875) $1783

134,602Bloodstream $36,441 (37,078) $1822107,156

Vent. Associated

Pneumonia

$9669 (2920) $790412,034

Urinary Tract

(UTI)

$1006 (503) $650 - 1361

Attributable Costs

70 studies: 39 US, 17 Europe, 4 Australia/New Zealand, 10 others. Analysis includes

only those studies that calculated individual (vs. aggregate) cost of patient outcomes.

SOURCE: Stone et al.AJICNov 2005; 33:501-509

HAI Cost Analysis January 2001

June 2004


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SOURCE: Eli N. Perencevich EP, Stone P, Wright, SB , t al.Infect Control Hosp Epidemiol2007;28:1121-1133

Attributable Costs and ExcessLength of Stay Associated with HAI


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Volumes and patient flow = $$$

Patients without HAI are discharged sooner

New patients move into those beds

Assuming fixed costs stay the same (building, utilities, etc.),available bed-days increase volumes and revenue,reimbursement.

Example: Table 1. shows CABG SSI mean excess LOS = 26 days.

*Preventing 10 CABG SSI would open up 260 bed-days. Ifaverage LOS without complication is 4 days, then 65 newpatients could be admitted.

*Modified from: Perencevich, Stone, Wright


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Attributable CostsThe services provided and billed to a patient that were caused

by an HAI.

Best to use local data ( financial partner).

Published data can be used as surrogate.

e.g., patient with hip joint SSI is compared to a matchedpatient with same surgery and other characteristics, but notthe SSI

Source: Murphy, D, Whiting, CS. Dispelling the myths: The true cost of Healthcare -

Associated Infections. APIC briefing; February 2007.


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Comparison of Economics Patients With and Without Central Line-Associated

Bloodstream InfectionN = 20 Patient

Admit diagnosis Respiratory failure Respiratory failure

Age 71 75

Payer Medicare +

commercial

Medicare +

commercial

Revenue $ 20,792 20,417

Expense $ 19,501 37,075

Gross margin $ +1,291 -16,658

Costs attr ibutable to

BSI

13,696

LOS (days) 10 15

SOURCE: Shannon et al. Amer J Med Qual i tyNov/Dec 2006; pgs 7S-16S


12/44Source: http://www.safetyleaders.org/greenlight/HAIcostCalculator.jsp/


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The Burden of HAI

> 99,000 death per year in United States

Increased ICU stay 8 days

Increased average hospital stay: 7.4 -9.4 days

Total dollar cost: $4.5-$5.7 billion

Average cost per infection: $13,973

Increase total cost / patient who survived ~$40,000.


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Business Case From the perspective of all stakeholders: Administrative

leadership, consumer, infection preventionist

Impact:1. Clinical quality/outcomes: Morbidity and mortality

2. Cost

Communicate value to decision-makers to justify existingprogram or to obtain additional resources -- Must showreturn on investment (ROI)


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Components of Total CostsDirect Costs

Direct payment for healthcare goods and services

Indirect Costs Lost work productivity

Intangible Costs

Cannot easily assign a monetary value

Opportunity Costs

What you give up when you use a resource


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Applying. to IPC PracticeDirect cost savings:

No routine ventilator circuit changes

$1M savings across BJC (equipment/supplies)

Indirect cost savings

Increase in respiratory therapist productivity due to fewervent circuit changes (focus on reducing VAP)

25% increase in flu vaccine (lower RN absenteeism/agency costs)

Source: Denise Murphy, The Business case for infection control: Knowledge, Tools,

Timing, Chicago APIC, 2009.


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Intangible Costs Physical pain and discomfort

Prolonged or permanent

disability Disruption to patient and family

Emotional/social burden

Decreased trust in the healthcare system

Increased use of antibiotics (emerging MDROs)


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Other Dimensions of CostsFixed costs

Costs incurred for fixed inputs

Cannot easily be eliminated in the short run Buildings

Variable costs

Costs incurred for variable inputs

Can easily be eliminated in the short run

Labor

SOURCE: C.S. Hollenbeak, 2006


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Estimation Methods Compare costs for patients with infections to patients

without infections (matched comparison; like case-controlstudy)

Problem: are the patients who get infection just like thosewho do not?

Age

Gender

DiabetesSmoking

Weight

SOURCE: C.S. Hollenbeak, 2006


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Who Should Be Involved In Business CaseDevelopment for Infection Prevention?

This doesnt need to be a one-person project

Multi-disciplinary: Finance partner, infection preventionist,quality experts, leaders in the area of interest

Key is to obtain true engagement by

stakeholders

Identify an opportunity

that will motivate interest


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What is the Need?

Assess Program ( gap analysis)

Outcomes: CLABSI, VAP, SSI, CAUTI, MRSA ?

Processes: Impact of interventions on outcome, Evidence-based practice being used? Hard-wired?

Does decision-making leadership have concerns?

Choose an area of opportunity

High Infection rate; high mortality/ morbidity; high cost

Conduct literature review to identify best practice


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Business Case continuedAddresses the business need that the project seeks to resolve.

1. Purpose

2. Expected benefits: Business: cost savings/ avoidance, reduced Length of stay

Quality: infection elimination >> improved outcomes

Intangible benefits (while soft, good to mention)

3. Options (e.g., doing nothing, implementing bundle)4. Expected costs/include risk of doing nothing

5. Gap analysis

6. Plan to communicate impact of plan/ interventions


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Keys to a Successful Plan

Clear and Concise

Communication, Communication, Communication!!!

1. Who should present? The infection preventionist may notbe best person to do so? What if finance presented it?!

2. Discussions with key decision makers: Are the costestimates, etc. going to be acceptable?


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Barnes Jewish Hospital:Impact of Interventions to Decrease HAIs

CABG Surgical Site 2000 2004 Impact of Interventions

#SSI 43 14 -25%SSI 6.8% 5.6% -18%

Excess Cost $825,000 $ 322,610 -$502,390

Spinal Surgical Site Infections (SSI)

#SSI 20 5 -15

%SSI 2.07% 0.8% -61%

Excess Cost $716,345 $659,394 -$90,000Bloodstream Infections (BSI)

#BSI 309 87 -222

BSI/1,000 patient days 8.4/1,000 1.5/1,000 -82%

Excess Cost $2,639,520 $2,639,540 -$107,140

#VAP 166 73 -93VAP/1,000 ventilator days 10.1/1000 4.8/1,000 -52%

Excess Cost $1,382,780 $632,180 -$750,600

Total Cost of All HAI tracked $3,955,225 $1,459,303 -$2,495,924

Ventilator Associated Pneumonia (VAP)

Source: Murphy D, Whiting, J. Dispelling the Myths: The True Cost of Healthcare-Associated

Infections, An APIC Briefing: February 2007.


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Call To Action Identify financial partner

Quantify the economic impact of HAIs

Based on economic analysis, target high-risk, high-volumeprocedure or pt population and lead efforts to eliminate HAIs

Ensure Specialists are educating HCWs about infectionprevention and driving evidence base practice

Identify process defects and intervene Measure the results and repeat the process

Source: Murphy D, Whiting, J. Dispelling the Myths: The True Cost of Healthcare-Associated

Infections, An APIC Briefing: February 2007.


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Results First Demonstrate Value (return on investment)

A great case for enhancing resources

Succeed, then ask

Source: Murphy D, Whiting, J. Dispelling the Myths: The True Cost of Healthcare-

Associated Infections, An APIC Briefing: February 2007


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Excess cost of HAIs $1 million*

% preventable with effective IC 32%

Costs prevented $320,000

Cost of program $200,000

Net Benefit $120,000Must always subtract program costs

from potential cost savings!

Source: Haley, JAMA 1987; 257:1611-1614. *1985

Know the Cost-Benefit

Impact of Prevention


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Plan for the Resources Needed:Sample IPC Program Budget

Acct. Desc. Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total

Salaries (Professional)

Salary (Clerical)

Misc. Benefits

Minor Equip.

PCs

Software

Office Supp.

Publications

TelephoneEducation

Postage

Travel

Special Events

Printing Purchased

Purchase MD Services

Lab


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Demonstrate VALUE Eliminate waste/improving productivity through:

Wise product selection

Appropriate application of expensive technology Sensible policies and procedures

Protection of employees from injury

Maintain regulatory/Joint Commission compliance

Facilitate effective collaboration between clinicians/administration Create a safer environment for patients and staff, increasing

satisfaction

Help to maintain organizational reputation for service excellence


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Secure Resources to Support EffectivePrograms

What is NOT BEING DONE due to inadequate resources THATSHOULD BE DONE to improve outcomes/quality

IC resources should be allocated based on:

Demographics of population

Most common diagnosis

High risk populations Services offered

Type and volume of procedures performed

Source:OBoyle C, Jackson MM, Henly SJ. Staffing requirements for infection control

programs in US Health care facilities: Delphi project. AJIC 2002;30;6:321-33.


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The Business Case? Negotiate Every Year: Routinely communicate value. Market

yourself >> Does the CEO, CFO know you and what you do?

Look outside FTEs for additional help if organization doesntwant to increase FTEs, but is open to other venues:

- Database/ software >> increase productivity

- Students who need projects

- Hospital Foundation may fund project

Continue to reduce healthcare-associated infections


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Infection-Related Claims

Claim frequency is increasing:

Increased availability of public data; and

Increased transparency, resulting in:

In the past = known risk of treatment

Currently = believe a preventable injury


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Infection developing during hospitalization (even in severelyimmuno-compromised patients)

Contaminated medications prepared by New EnglandCompounding Center (NECC) Notification of > 4000patients.

Shared multi-dose vials Insulin syringe on one patient usedon another patient. 25% of practitioners re-enter vials with previously used

needles

Examples of Claims


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Additional Costs


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Average loss $210,000

Average indemnity payment $414,000

Patient outcome: 25% cases involved high severity injury

16% cases resulted in deaths (CRICO/RMF)

Recent high verdict/settlement cases

$13.5 M bacterial infection in MA $16 M infection following delivery in UT

$5.5 M & $3 M delays in treating infection in PA

$2.58 million infection after pacemaker in MO

Healthcare Associated Infection Cases


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Evaluating Impact

10Extremely

rare

Sentinel Event -

adverse outcome10

No warning, impact is

immediate

Products Liability;

Human factors10

> 80 % patients

served (or

procedures/year)

Medications 10

Immediate and

Direct Patient and

Organizational

Outcome(s)

Patient outcome

with Regulatory

Impact (i.e.

sanctions and/or

fine(s))

8 RareSentinuel Event -

no harm to

patient

8

Warning occurs over shortest

period of time (days)

providing little opportunity to

adjust or react

Staffing issue 860 - 80% patients

servedRadiology 8

Direct Regulatory

Impact

Mandatory

Reporting

6 PeriodicSerious Event -

adverse outcome 6

Warning occurs over shorter

period of time (weeks)

providing some opportunity

to adjust or react

Systems issue 640 - 60% patients

servedSurgery 6

Patient outcome

or potential for

organizational

outcome

Serious Event -

adverse outcome

4 Recurrent Serious Event - noharm to patient 4Warning occurs over months

providing opportunity to

adjust or react

Processes or poli cies 4 20 - 40% patientsserved Procedure 4Minor patient

outcome to few

individuals

Serious Event -

near miss; Reques

Service Recovery

Efforts of multip le

staff;

2Occurs

frequently

Unanticipated

event2

Warning occurs over years

with documented trend

providing opportunity to

adjust or react

Infrastructure/building

/fixtures2 < 20% patients served

Infections;

Falls2

Client

dissatisfaction

handled locally

Minor

unanticipated

event or

dissatisfaction

Score = (Probability + Time to Impact + Scope) x Severity

Frequency Warning Scope Outcome

Score= Frequency+Warning+Scope+Outcome+Severity


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Risk Management assesses events toidentify the amount of:

Resources including people and

liability activity to assist with Prioritization

Developed by Sharon Dunning, MBA,RN, manager, risk management,Greenville Health System

Evaluating Impact Continued


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CJD case

Diagnosed post mortem, 10 patients impacted

Disclosures made to families>> Legal Sanctions likely>>costhigh

Frequency + Warning+ Scope+ Outcome+ Severity = Score

10 10 2 10 10 42

Evaluating Impact Example


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Catheter Associated UTIs

Hospital just beginning initiative to reduce

Assessment shows that 30% of pts have Foleys and are at risk

CAUTI rates are high/processes are not being following

Frequency + Warning+ Scope+ Outcome+ Severity = Score

2 2 4 8 2 18

Impact Example


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Cost/Benefit Analysis

Developed by Sharon Dunning, MBA, RN, manager, riskmanagement, Greenville Health System


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Questions?

Connie Steed, MSN, RN, CIC

Phone: 864-455-6267

Email: [email protected]

the big picture of making the business case for infection prevention and control

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